SERIES: FLEXIBLE BRONCHOSCOPY IN CHILDRENBronchoscopy in paediatric intensive care
Section snippets
INTRODUCTION
Superficially, paediatric intensive care is a most attractive setting for a bronchoscopy. The child is almost invariably intubated and heavily sedated, is often paralysed and is always closely monitored. There are intensivists present who are highly skilled in assessing sick children. Nothing could apparently be more easy than to slip a bronchoscope down the endotracheal tube and examine the lower airway. However, in no context can rashly proceeding with an ill-considered examination produce
GENERAL EFFECTS OF BRONCHOSCOPY
The general problems of bronchoscopy, such as hypoxia, hypercapnia and the application of inadvertent positive end-expiratory pressure (PEEP) are even more important in paediatric intensive care,2., 3. where the child will, by definition, be in a critical condition and especially vulnerable to cardiovascular instability. Hypoxia can usually be overcome by increasing the FiO2, but hypercapnia alone can be a cause of pulmonary vasoconstriction,1 probably but not certainly, by a direct effect
INSTRUMENTS AVAILABLE
Standard fibrescopes are 2.7, 3.6 or 4.9 mm in external diameter (Table 1); these are not suitable for very preterm babies. The biopsy channel is 1.2 mm (for the 2.7 and 3.6 mm instruments) and 2.2 mm (for the 4.9 mm bronchoscope). Forceps for biopsy are available for all these instruments. Neonatal bronchoscopes are 2.2 mm in external diameter. There are two types: a steerable version and one with a suction channel, but both features do not appear in any one bronchoscope. The scope of procedures
Endobronchial toilet
Lobar and segmental collapse should first be treated with conventional physiotherapy. Inhaled and intratracheal recombinant human DNAase (rhDNase) has been reported anecdotally to be of benefit in segmental collapse even in children who do not have cystic fibrosis.19., 20., 21. If this fails, bronchoscopy is performed. First, unexpected airway pathology may be detected: the collapse may, for example, actually be caused not by mucus plugging but by vascular compression, which is not treatable by
ASSOCIATED DISEASE
Bronchoscopy is occasionally indicated to assess the presence or otherwise of diseases associated with the primary abnormality. Examples include a complete cartilage ring (associated with pulmonary artery sling) or a vascular ring.33 If congenital lung disease is suspected, bronchoscopy to assess airway anatomy and any blind-ending pouches should be considered.
A frequent referral for bronchoscopy is the child with severe chronic lung disease of prematurity. The procedure is not without risk in
NEW DISEASES
We constantly need to be on the alert for new complications of modern treatment. We have recently described37 avascular necrosis of the trachea secondary to unifocalisation for pulmonary atresia (Fig. 6). Post-surgical problems range from complete tracheal necrosis to mucosal ischaemia presenting as a wheeze refractory to treatment, with recovery over time. It is likely that further iatrogenic disease will be discovered in the future.
CONCLUSION
Bronchoscopy is a very versatile technique in the context of intensive care and has many potentially valuable indications. Safety is of paramount importance and the risks in critically unstable patients are correspondingly greater. The procedure is, however, very safe, if it is performed by experienced operators with back-up from doctors skilled in airway management and the monitoring of sick children.
PRACTICE POINTS
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Bronchoscopy in intensive care is deceptively easy to perform but if care is not taken, the child may be critically destabilised.
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A second person with airway management skills, other than the bronchoscopist, should monitor the child throughout the procedure.
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A flexible bronchoscope blocks a significant part of the airway and hypoxia, hypercapnia, auto-positive end-expiratory pressure and raised intracranial pressure may result.
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The early use of fibre-optic bronchoscopy to guide the therapy of
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